Download Postpartum Hemorrhage Protocol

OWNING DEPARTMENT
St. John Health System
Labor and Delivery 6 WEST
Postpartum 6 EAST
ST. JOHN MEDICAL CENTER
PAGE
Postpartum Hemorrhage
1
OF
5
DATE APPROVED:
I. Department Applies To- Labor and Delivery, 6 East Postpartum
II. Overview
Postpartum Hemorrhage: An estimated blood loss in excess of 500 mL following a vaginal birth or a
loss of greater than 1,000 mL following cesarean birth
III. Policy
A. Indications- Postpartum with cumulative blood loss >500 mL after vaginal birth or >1000 mL
after cesarean birth
B. Contraindications - Hysterectomy after delivery
IV. Procedure
A. Upon admission to L&D or PP/AP unit, every patient will be screened and OB Hemorrhage
Risk Level will be documented on the patient’s record.
1. Evaluate for risks developed during the Labor/Delivery/Recovery process and re-assess OB
Hemorrhage Risk Level as needed
2. Patients with 2 or more medium risk factors are considered High Risk.
B. Group, Type & Screen (GTS) will be obtained for every patient
C. Identify patients who may decline blood products and document
1. Notify delivering physician, OB hospitalist and anesthesiologist
2. Review consent form and ensure declination of blood form is signed if applicable
D. Notify physician that patient meets High Risk criteria.
E.
Place ORDER SET in every patient chart
F.
At delivery, both vaginal and Cesarean Section (C/S), blood loss will be measured
quantitatively using formal methods, such as graduated containers and/or weight of blood
soaked materials (1 gm = 1 mL).
G. Following delivery, blood loss will continue to be measured, every 15 minutes, until the patient
status changes to routine PP care.
1. During this time, an appropriate Stage of OB hemorrhage will be documented in the delivery
record
2. Notify Physician if patient status is Stage 1 or higher and initiate the POSTPARTUM
HEMORRHAGE PROTOCOL AND ORDER SET
REPLACES PREVIOUS DOCUMENT TITLE/NUMBER
PREPARED BY
N/A - New
Sherry Batterson RN
Ellen Mayberry BSN, RNC-OB
Carissa Shaw, BSN, RNC-OB
Regina Wilcox, BSN, RN
REPLACES DOCUMENT DATED
APPROVER
N/A - New
OWNING DEPARTMENT
St. John Health System
Labor and Delivery 6 WEST
Postpartum 6 EAST
ST. JOHN MEDICAL CENTER
PAGE
Postpartum Hemorrhage
OB Hemorrhage
STAGE
STAGE 0
OF
5
DATE APPROVED:
PROCEDURE PER PROTOCOL
ALL BIRTHS
STAGE 1
2
•
•
•
Infuse increased rate of oxytocin after delivery per physician order
Obtain quantitative measurements of blood loss
Ongoing evaluation of Vital Signs and fundal properties
If Cumulative Blood Loss >500 mL for vaginal birth or >1000 mL for cesarean birth
OR vital signs > 15% change OR Increased bleeding during recovery or postpartum THEN
PROCEED TO STAGE 1
• Ensure OBGYN physician is present
• Maintain patent IV access
• Increase IV oxytocin rate and titrate infusion rate per uterine tone
• Continue vigorous fundal massage every 15 minutes
• Empty bladder: straight catheter or place indwelling catheter with urometer per order
• Administer medications per ORDER SET
• Vital signs every 15 minutes, continuous pulse ox
• Obtain and record Quantitative measurement of blood loss q 10-15 min
• Administer O2 to maintain saturation at >95%
• Maintain I&O’s
• Keep patient warm
• Type and Crossmatch 2 units PRBCs (if not already done) as ordered by physician, notify
Blood Bank for potential preparation of OB Pack
• Obtain CBC, if platelets < 100,000 draw DIC profile
STAGE 2
•
•
•
•
•
•
•
If continued bleeding with blood loss up to 1500 ml
cumulative blood loss OR continued vital sign instability,
PROCEED TO STAGE 2
Notify anesthesia potential for:
o D&C
o Bakri Balloon placement
o Packing or repair as required
o Uterine Artery Ligation
o Hypogastric ligation
o Selective embolization (IR)
o B-Lynch or Hysterectomy
Establish 2nd large bore IV
Assess and announce VS and cumulative blood loss q 5-10 min
Administer meds, blood products and draw labs per ORDER SET, as requested by physican
Keep patient warm
Place indwelling catheter with urometer (if not already done)
Upon physician order, Transfuse 2 units PRBCs per protocol
REPLACES PREVIOUS DOCUMENT TITLE/NUMBER
PREPARED BY
N/A - New
Sherry Batterson RN
Ellen Mayberry BSN, RNC-OB
Carissa Shaw, BSN, RNC-OB
Regina Wilcox, BSN, RN
REPLACES DOCUMENT DATED
APPROVER
N/A - New
OWNING DEPARTMENT
St. John Health System
Labor and Delivery 6 WEST
Postpartum 6 EAST
ST. JOHN MEDICAL CENTER
PAGE
Postpartum Hemorrhage
3
OF
5
DATE APPROVED:
If cumulative blood loss >1500 mL,
VS unstable OR Suspicion for DIC
PROCEED TO STAGE 3
STAGE 3
•
•
•
•
•
•
•
Move patient to OR (if not already there)
Upon physician order, TRANSFUSE AGGRESSIVELY. Order OB Pack (4:4:1) from
Blood Bank.
Notify House Supervisor about possible transfer to ICU
Announce VS and cumulative blood loss q 5-10 min
Apply upper body warming blanket if feasible
Use fluid warmer and/or rapid infuser for fluid/blood products
Apply SCDs
(California Maternal Quality Care Collaborative [CMQCC], 2009)
V. Definitions
A. Admission OB Hemorrhage Risk Levels
1. Low:
a) No previous uterine incision
b) Singleton Pregnancy
c) <4 previous vaginal births
d) No known bleeding disorders
e) No history of PPH
f) BMI < 30
2. Medium:
a) Prior cesarean birth(s) or uterine surgery
b) Multiple gestation
c) History of PPH
d) 4 or more previous vaginal births
e) Chorioamnionitis
f) Large uterine fibroids
g) Polyhydramnios
h) History of previous PPH
i) Estimated fetal weight 4000 gm or greater
j) BMI > 30
REPLACES PREVIOUS DOCUMENT TITLE/NUMBER
PREPARED BY
N/A - New
Sherry Batterson RN
Ellen Mayberry BSN, RNC-OB
Carissa Shaw, BSN, RNC-OB
Regina Wilcox, BSN, RN
REPLACES DOCUMENT DATED
APPROVER
N/A - New
OWNING DEPARTMENT
St. John Health System
Labor and Delivery 6 WEST
Postpartum 6 EAST
ST. JOHN MEDICAL CENTER
PAGE
Postpartum Hemorrhage
4
OF
5
DATE APPROVED:
3. High:
a) Placenta previa, low lying placenta
b. Suspected placenta accreta or percreta
c) Hematocrit <30% AND any additional medium risk factors
d) Platelets <100,000
e) Active bleeding (greater than show) on admission
f) Known coagulopathy
g) Anticoagulant therapy
B.
Initial Post Delivery Hemorrhage Risk Levels
1. Low:
a) Singleton pregnancy
b) Less than 5 total vaginal births
c) No known bleeding disorder
d) No history of PPH
e) Uncomplicated vaginal delivery
f) No genital tract trauma
2. Medium:
a) Cesarean birth or uterine surgery
b) Multiple gestation
c) Polyhydramnios
d) Greater than or equal to 5 total vaginal deliveries
e) Chorioamnionitis
f) History of previous PPH
g) Large uterine fibroids or uterine anomaly
h) Prolonged active labor > 12 hr.
i) Prolonged Oxytocin use
j) Rapid labor
k) Application of forceps or vacuum
l) Genital tract trauma
m) Shoulder dystocia
n) Magnesium Sulfate treatment
3. High:
a) Hematocrit less than 30% AND other medium or high risk factors present
b) Platelets less than 100,000
c) Anticoagulant therapy
REPLACES PREVIOUS DOCUMENT TITLE/NUMBER
PREPARED BY
N/A - New
Sherry Batterson RN
Ellen Mayberry BSN, RNC-OB
Carissa Shaw, BSN, RNC-OB
Regina Wilcox, BSN, RN
REPLACES DOCUMENT DATED
APPROVER
N/A - New
OWNING DEPARTMENT
St. John Health System
Labor and Delivery 6 WEST
Postpartum 6 EAST
ST. JOHN MEDICAL CENTER
PAGE
Postpartum Hemorrhage
5
OF
5
DATE APPROVED:
d) Known coagulopathy
e) Active bleeding
(CMQCC, 2009)
VI. References
The American College of Obstetricians and Gynecologists (ACOG). (2006). ACOG Practice Bulletin
Number 76. Postpartum Hemorrhage.
California Maternal Quality Care Collaboration (CMQCC). (2009). OB Hemorrhage Toolkit. Retrieved
from http://www.cmqcc.org/ob_hemorrhage
VII. Keywords
Postpartum Hemorrhage, Obstetric Hemorrhage, Obstetric Emergencies
REPLACES PREVIOUS DOCUMENT TITLE/NUMBER
PREPARED BY
N/A - New
Sherry Batterson RN
Ellen Mayberry BSN, RNC-OB
Carissa Shaw, BSN, RNC-OB
Regina Wilcox, BSN, RN
REPLACES DOCUMENT DATED
APPROVER
N/A - New